Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Abstract

Background: Less than half of eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to describe physicians' reasons for screening or not screening specific patients for CRC and their approach to CRC testing discussions.Methods: This study used mixed-methods. Physicians described their reasons for screening or not screening 6 randomly chosen patients who were eligible for CRC screening (3 screened and 3 not screened) whose CRC testing status was ascertained by medical record review. Verbatim transcripts from physicians responding to structured interview questions were used to identify themes. Specific elements of discussion were examined for their association with each physician's screening rate. Fifteen randomly chosen Iowa family physicians from the Iowa Research Network stratified by privileges to perform colonoscopy, flexible sigmoidoscopy, or neither procedure dictated the reasons why 43 patients were screened and 40 patients were not screened.Results: Reasons patients were not up to date fell into 2 major categories: (1) no discussion by physician (50%) and (2) patient refusal (43%). Reasons for no discussion included lack of opportunity, assessment that cost would be prohibitive, distraction by other life issues/health problems, physician forgetfulness, and expected patient refusal. Patients declined because of cost, lack of interest, autonomy, other life issues, fear of screening, and lack of symptoms. Patients who were up to date received (1) diagnostic testing (for previous colon pathology or symptoms; 56%) or (2) asymptomatic screening (44%). Physicians who were more adamant about screening had higher screening rates (P < .05; Wilcoxon rank sum). Physicians framed their recommendations differently ("I recommend" vs "They recommend"), with lower screening rates among physicians who used "they recommend" (P ‫؍‬ .05; Wilcoxon rank sum).Conclusions: Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2)

Higher Physician Density is Associated with Lower Incidence of Late-stage Colorectal Cancer

“…This is further supported by the fact that after the initiation of Medicare coverage of colonoscopy for average-risk CRC, gastroenterologist density became more strongly associated with reduced late-stage CRC incidence than prior to such coverage. Physician recommendation is an important determinant of CRC screening [24][25][26] with individuals with more frequent physician contact being more likely to undergo screening 27 . Inadequate physician time with the patient is another barrier to screening 25 .…”

“…As physician recommendation is a key determinant of patients' acceptance of screening, adequate access may be an important contributor to disparity. Frequency of physician contact as well as time spent during individual visits may influence screening [24][25][26][27] . Higher physician-perpopulation ratio may improve access, decrease waiting times and increase the opportunity for contact between the patient and physician.…”

Mailed Fecal Immunochemical Tests Plus Educational Materials to Improve Colon Cancer Screening Rates in Iowa Research Network (IRENE) Practices

“…The questionnaire has been tested extensively with more than 500 participants in a previous study. 9,21 Although developed independently of Vernon et al's 22 instrument, many of the questions designed to ascertain screening status were very similar to the questions developed by Vernon et al The subject's answers on the baseline questionnaire were used to determine eligibility for the study. Subjects were considered ineligible if they self-reported being up to date with CRC screening by any method (fecal occult or FIT within the past year, barium enema or flexible sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years).…”

A Randomized Controlled Trial to Improve Colon Cancer Screening in Rural Family Medicine: An Iowa Research Network (IRENE) Study

“…The questionnaire was tested and revised after being using in a previous study of 500 participants. 12,25 Although they were developed independent of another questionnaire designed to assess CRC screening behaviors, many of the questions were similar. 26 The answers on the baseline questionnaire were used to determine eligibility.…”